How can clinical teams address repeated violations of tobacco-free policies?​

We asked an advanced practice clinician, a drug treatment program manager, a client, a security manager, a tobacco-free project manager and a county-city health unit manager. Here's what they say:

Advanced practice clinician in complex mental health program

There are many ways to approach repeated violations of tobacco-free policies. One way is to hold a tobacco consultation to find out why a client is violating the policy. It could be a misunderstanding, a lack of tobacco treatment such as optimal nicotine replacement therapy (NRT) or a lack of group-based programming. Does the client know about tobacco groups he or she can access? Is the client being motivated to access these groups?

Enforcement is another issue to consider: Are clinical teams using protocols to help them enforce the policy? Sometimes that means simply having a conversation with the client about the policy and how clients have to adhere to it. Other times it gets a little starker, where you can curtail privileges or trespass clients on CAMH grounds if they're not adhering to policy. In some cases, a client who is not adhering to policy and who is clinically ready can be discharged from hospital.

Those are some of the worst-case scenarios, but we're really trying to use a tobacco cessation and awareness approach—trying to get clients into a conversation about what they need and helping them adhere to the policy, whether it means starting NRT, getting more NRT, going to a tobacco group or developing a strategy to help them comply with the policy.

Ideally we would approach tobacco policy violations from a consultation or clinical point of view first and foremost, and the last resort would be enforcement protocols. There will be clients who oppose this policy and who continue to smoke on the grounds, whether that's because of cognitive issues or behavioural opposition. We have to figure that out as well.

We have point people across the hospital who can provide clinical teams with expert consultations to help them navigate this new policy, but I don't think this service is widely known. It is in the CAMH tobacco toolkit, but it hasn't been advertised to the extent that maybe it should have been.

Clinical teams get frustrated because they have clients who are considered "frequent flyers." This repeated behaviour leads to staff feeling demoralized and wondering why they should go through all these hoops if the client is going to ignore the requests anyway.

We also have to do a better job of screening clients at the door for tobacco-related issues, which will help us get a sense of what we're dealing with, whether it's NRT issues or group-based programming or enforcement. It really does come down to the front line—asking those screening questions so that we can assess up front a client's tobacco use status.

The tobacco-free policy isn't about telling people to stop smoking. It's about building our awareness of clients' tobacco status and building their awareness of their tobacco use—moving them along the stages of change, from pre-contemplation to trying some NRT or attending a tobacco group. It's not about being hard core and policing tobacco. It's about awareness and giving clients options so they can either contemplate or take some action on their tobacco use.

Drug treatment program manager

Addressing repeated violations of the tobacco policy is certainly a challenge. It is very important not to rush into a "quick fix." Usually quick fixes around policy compliance involve added rules and some form of punishment. In some cases, service is restricted. Dealing with the issue requires a measured approach that considers individual clients, the client community as a whole and the organization's goals, along with an outlook that recognizes that these are components of the treatment process as much as missing appointments, not participating in groups or being late. If we view policy violations as a clinical issue, we consider the following approaches:

• Use a consistent message and an individual approach: First of all, a consistent team message is important. This does not necessarily mean having exactly the same approach for each client. It is always important to tap into the internal motivation factors for each client. For example, one client may be motivated by her own health to stop smoking, whereas another may be motivated by empathy for others who are trying to quit.
• Recognize power perceptions: Policies that restrict clients in some way often make clients feel that their personal power is being taken away—and they already feel that they have lost much of their power. It is quite "normal" that they fight the "rule," especially when the policy is first implemented.
• Reduce judgment and stigmatization: Acknowledge that stopping tobacco use is difficult.
• Educate: Help clients understand the "why" behind the tobacco-free policy. You can do this in various ways. A one-time education session likely will not work well, and a lecture even less. If clients don't want the change they probably have not been able to focus on the message and perhaps have not made it past the first minute of the session.
• Have patience: Changing behaviour is a process, not an event. Delaying gratification (the pleasurable effects of nicotine and smoking), following rules, being aware of the impact on others, dealing with stress and change (and the stress change produces), and being aware of and giving up habits are behavioural changes.

But . . .

When you use these approaches and the person continues to violate the policy, what then? Go back and try it all again—be creative, find more ways to reach the person's "internal motivation," get assistance from team members and others. And remember that whenever we ask clients to evaluate their own behaviour or to do something differently, we are withdrawing from the "therapeutic rapport bank"—there is an ebb and flow to this work—and we have to always be mindful of when that bank needs a deposit.

Client

On searches

The new tobacco-free policy at CAMH prohibits the possession of tobacco and related products on units, adding to the list of items that are grounds for searching a client or patient.

There are a few things to bear in mind when conducting a search. People may ask why they are being searched and may be unreceptive to a search for reasons that have nothing to do with tobacco. I've heard the question posed, in hospitals and elsewhere, "Why would someone object to being searched if they have nothing to hide?" There are many reasons:  

• Unlike the pat-down that everyone attending a rock concert must undergo, not everyone in a tobacco-free environment is searched for tobacco. Singling out individuals implies a level of distrust and suspicion, which can be particularly troubling in the place you consider your home, which CAMH is for some people.
• People with substance use histories and mental health diagnoses are generally portrayed as untrustworthy by society. This was highlighted in the video by the Toronto Policing Literacy Initiative.
• People may just want an explanation, unrelated to any personal history of being searched or stigma.
• For some people, searches are violating. Due to the authority CAMH has, courtesy of legislation, procedures such as searches, detention and restraints (be they tying someone up or drugging them) are legal. But this authority comes with a great deal of responsibility, because it is in many respects a legislative exemption from criminal law. Just because CAMH can legally carry out certain procedures does not mean that clients will experience them any differently than if they occurred external to CAMH in a way that would be considered criminal.

On smoking on the grounds

Repeating the no-smoking message and delivering it with a smile are the best ways to go when enforcing no smoking on the property. Personal change is a process and breaking habits isn't easy. When a habit only has to be broken at CAMH once a week, or less often, it's going to be difficult for people. Tobacco resides in a different legal and social context than almost any other addictive substance. Tobacco and caffeine are the two substances that one can consume in public, and purchase, at any time of the day.

When you see someone using tobacco and remind them that they are in a tobacco-free environment, be gentle; and when they acquiesce, thank them.

Security manager

I don't think dealing with repeat violations of the tobacco-free policy is solely the responsibility of people in clinical roles. Instead, it requires an organizational effort. Addressing the issue is everyone's responsibility. The real question is "How can we support people around the tobacco-free policy?"

Part of the discussions with security staff involve establishing ways to support clinical staff with the tough battle they have ahead of them, whether it is calling on colleagues who are floors above and below, contacting security for assistance or educating clients. These are all strategies that can assist staff who have to address concerns about the policy.

The first thing clinical staff need to know is what supports are available to them. These processes are being discussed and put into place. Clinical staff, in fact, all staff, need to know what these processes and supports are. They must be communicated well, there has to be ownership for individuals, no matter what level of the organization.

We are all accountable for all policies. A lot of people have strong personal feelings for or against the policy, but they need to put those feelings aside.

Tobacco free project manager

As an organization-wide policy, the tobacco-free policy at CAMH applies not only to clients and visitors, but also to all staff, physicians and volunteers. This means that we all have a role in supporting co-operation with the policy. Consistent messaging and reminders that we are a tobacco-free campus will communicate the expectation that people on our campus support a healing environment by refraining from smoking, visibly possessing tobacco or otherwise triggering tobacco use.

We understand that implementing and adhering to the policy will be a challenge, so we have established resources to support its adoption and integration. These resources will help to identify people who may have difficulty co-operating with the policy and to then develop strategies to support these people through this change. These strategies include education, clinical support, no-cost NRT and behavioural support.

Prior to arrival at CAMH

Usually people smoking on our campus are unaware of our tobacco-free policy and so are unintentionally violating it. To raise awareness, we are using signage and updates to our voice mail messages to inform people about the policy before they come here or when they are entering our campus. We strongly recommend that at the time of scheduling an appointment, the person be advised of our tobacco-free and scent-free policies. These efforts to increase awareness and mindfulness aim to reduce incidents of tobacco use on our campus.

To this end, a tobacco-free policy brochure is now included in the welcome package that clients and patients get at admission. This plain language summary explains what the policy means and whom clients and patients can contact if they have questions or concerns.

Once at CAMH

All new inpatients should be screened for tobacco use and offered behavioural support and free NRT to support them throughout their stay. The expectation is not that they quit smoking. However, because inpatients may have restrictions to their passes and privileges, and therefore may not be able to obtain adequate levels of nicotine, NRTs are provided to keep them comfortable and out of nicotine withdrawal.

Questions have been raised about the safety of NRT for people who continue to smoke. There is no evidence to suggest that using the patch in combination with smoking is more damaging than smoking alone. For more information about NRT, see the following resources:

• Overview of nicotine replacement therapy (NRT)
• Recommending nicotine replacement therapy (NRT)

There are occasions when people prefer not to use, or unable to use the patch or other forms of NRT. These patients may need other clinical strategies to support them.

Patients who may struggle with this policy can consult with advanced practice clinicians and nurses. These consultations can lead to clinical strategies that consider contributing factors that may lead to policy violations. For example, are there cognitive barriers or language or cultural barriers to understanding or communicating the policy? Does the person have unique challenges such as mobility issues, oppositional/deviant behaviour or secondary gain from trafficking cigarettes on the unit or the grounds? Is there an inconsistent approaches to the tobacco policy on the unit?

The consultation can also discuss available supports, such as:

• NRT
• family and visitor discussions
• wellness and cessation supports
• motivational interviewing approaches
• case conferences
• contingency management
• peer support
• interpreters and signage to re-communicate and remind people about the policy.

However, despite our best efforts at providing interventions and supports, there will continue to be people who oppose the policy and intentionally violate it.

When policy violations happen inside CAMH facilities or outside on CAMH grounds

CAMH is a large property and people here include inpatients and outpatients (those who are here for services) as well as visitors – staff, community members or contract workers. There can be confusion about our policy.

Any staff who see someone smoking on the outdoor CAMH grounds are expected to approach the person and respectfully inform them that we are tobacco free. Staff are not required to ensure that the person leaves CAMH property to stop smoking. The purpose of this conversation is educational.

Our experience tells us that usually the person will comply without incident. Having this conversation and finding the correct wording may be difficult, so the tobacco-free team has developed brochures to help staff have this conversation. If the situation escalates or the person becomes threatening or aggressive, staff are encouraged to contact security for support. If the conversation does not escalate but the person appears not to understand the policy, staff are encouraged to inform the clinical team managing this client or patient.

At CAMH, we are fortunate to have a wonderful team of community ambassadors. Their role is to create a welcoming presence in the community and support communication and education around the tobacco-free policy. This team has built a rapport with patients, clients, staff and visitors and can identify a patient to the clinical teams. The purpose of communicating with clinical teams is to provide a feedback loop so they know how a patient or client is managing with the policy.

Policy violations may indicate underlying issues, such as policy miscommunication (requiring re-education and communication about the policy), inadequate doses of NRT, incorrectly applied or misused NRT, cognitive barriers, language barriers or a change in mental status. These issues may require changing clinical management of the patient, so it is critical to share this kind of information with clinical teams. The purpose of this communication is therapeutic, not punitive.

If a patient or client is smoking indoors on CAMH property, staff must complete an incident report called a SCORE report (Staff and Client Online Reporting of Event). These reports notify management of the circumstances surrounding tobacco policy violations. They also help management to understand:

• unit-specific types of tobacco-free policy violations
• contributing factors leading to tobacco-free policy violations
• immediate actions taken to prevent recurrence.

SCORE reports of indoor tobacco use help managers to identify unit-specific considerations and strategies to support policy co-operation.

In some situations, tobacco policy violations may result in searching the patient. Searches are a part of routine practice for many patients and are done to ensure their safety, as well as that of co-patients, staff and visitors. Tobacco discovered on the unit will be taken and disposed of.

Discipline resulting from tobacco policy violations will be considered if clinical strategies have been exhausted and the patient continues to intentionally violate the policy. The kind of discipline will be decided on by the clinical unit and will be consistent with the CAMH model of care, which includes clinical considerations.

Is addressing tobacco use consistent within a harm reduction approach?

A 2011 journal article by Judith Prochaska, an expert in the field of tobacco dependence in marginalized or complex patients, discusses the harm of failing to address tobacco use while a person is in treatment for mental health and addictions concerns. The article supports research that indicates that continuing to smoke negatively affects mental health and addiction outcomes, and may even contribute to re-hospitalization.

Tobacco is the leading cause of mortality in our patient population. Failing to address tobacco use would be to promote harm, not health. Furthermore, providing free NRT is consistent with a harm reduction approach because NRT provides access to nicotine without the harmful chemicals contained in cigarettes.

Are there any smoking cessation supports for CAMH outpatients or persons in the community?

The Nicotine Dependence Service at CAMH (416 535-8501 ext 77400) helps people who want to quit tobacco. The following tobacco cessation resources are also available:

• Smokers' Helpline. Tel.: 1 877 513-5333
• The Lung Association. Tel.: 1 888 566-5864 or 1 888 344-LUNG (5864)
• Quit Now (text, phone and online services). Tel.: 1 877 455-2233

Manager, County-city health unit

Following the steps of policy development including assessing readiness, developing goals, objectives and policy options, identifying decision-makers, building support, and evaluating the policy helps ensure successful implementation of tobacco-free policies. It is also helpful when developing a tobacco –free policy to consult with an enforcement officer as they often have a unique perspective on such things as the wording and placement of signage and the use of the Provincial Offences Act.

In our experience, effective tobacco-free policy implementation requires identification and engagement of all stakeholders starting when the problem is first identified. Staff and the public need to fully understand the purpose and implications of the policy. A comprehensive education process and a communications strategy really help staff and other stakeholders understand and engage in the tobacco-free policy. Support for tobacco-users to abstain and/or quit using tobacco products is essential including access to counselling and pharmacotherapy.

Commitment by management to support staff time for ongoing training is essential so that staff feel comfortable and confident in supporting the policy. The Peterborough County-City Health Unit has developed a policy that supports training for all staff. This training provides staff with an opportunity to build their competence and confidence in managing a variety of scenarios.

However, if in spite of all of the aforementioned efforts violations continue to occur, effective enforcement of the policy is essential. In Peterborough, the smoke-free policy for both the Peterborough County-City Health Unit and the Peterborough Regional Health Centre properties is legislated through a City by-law. The by-law is an effective enforcement tool as it permits the designated enforcement officer to charge violators with a provincial offence. This acts as an additional deterrent and successfully reduces the number of repeat offenders.